Too often the entire focus of fertility recommendations are directed towards women. It is true that egg quality is the single most important factor in determining conception. That said, a healthy egg cannot overcome sperm with damaged DNA. So, let’s provide some guidance for what men should be doing with their food choices to improve the chance of a successful conception. http://nutritionfacts.org/video/male-fertility-and-diet/
We spend a lot of time and energy adjusting our patient’s thyroid hormone levels. This data helps explain why that is so important. Oftentimes a woman’s thyroid hormone is sufficient for her if she weren’t pregnant. That’s not always sufficient to foster healthy implantation. Check on the link below to learn more about why this is important.
We’re all frightened by what we don’t understand. Many infectious diseases feed in to that fear. Consider for example the recent media frenzy over Ebola Virus; then again over Bird Flu and then more recently over Chikungunya—all of which have died down without the nightmare scenarios coming to fruition. Now we’re focusing on Zika virus. This is admittedly scary due to its possible link to birth defects in babies born in Brazil. So let’s review what we know, what we don’t know AND what we can do in the meantime.
Recently the Society of Maternal-Fetal-Medicine held a special session to review this important topic and provide updated advice and guidance for women’s healthcare specialists in the USA. Zika is a virus transmitted by mosquitos. Those developing a symptomatic infection during pregnancy may be at high risk of having a child with a birth defect known as microcephaly. Although this link has not yet been definitively established it is recommended that we provide very close surveillance of any suspected cases while additional information is gathered. Although this sounds scary here are some of the key facts to keep in mind:
- Only 1 in 5 people bitten by an infected mosquito is likely to develop an infection
- Those infected have pretty specific symptoms including sore joints, a rash and conjunctivitis (red, swollen areas around the eyes)
- The infection will appear within one or two weeks of the mosquito bite
- The current test available is nonspecific and can create concerns due to false-positive results (a positive test due to a related virus that has not been linked with birth defects)
- The Center for Disease Control and Prevention is monitoring places in the world known to have active Zika transmission for travelers and advising those that are pregnant or planning pregnancy to avoid traveling to those locations
- Meanwhile, alternate causes of the fetal malformations are being investigated including a possible link to an insecticide widely used to control mosquitos in the area of Brazil most heavily effected by fetal microcephaly
Clearly we need to learn more about the Zika virus. In the meantime, here is some practical advice for patients that want to become pregnant:
- If possible avoid traveling to areas effected by Zika for at least one month prior to starting fertility treatment
- During mosquito season (as well as while traveling to effected areas) consider the following protective steps
- Wear long sleeves when possible and stay in air conditioned facilities (rather than using open windows for cooling
- Use insect repellants to reduce the risk of mosquito bites. Here are two that are among the safest (and least toxic) for women trying to conceive:
- If you live in an area with a high rate of Zika virus exposure, consider undergoing fertility treatment and freezing the embryos for delayed embryo transfer–a process known as embryo banking.
- If you develop the symptoms of rash, joint pain and red eyes, contact your healthcare provider to discussed current recommendations on testing.
- Stay informed. If you subscribe to this blog, I will do my best to remain current on this topic.
For the latest updated information from the CDC on this emerging problem, check out the following link: http://www.cdc.gov/zika/
Latest Update 02/29/2016: “It’s entirely possible there’s something else going on in Brazil — something unique to the population or environment in which transmission takes place.” – Dr. Anthony Fauci, Direct of National Institute for Allergy and Infectious disease
One of the most difficult subjects to discuss—especially for those treating or experiencing infertility—is miscarriage. Yet not talking about it often leads to unnecessary guilt, exacerbated shame and all too often to treatments of questionable value. So let’s review some of the most recent findings about this challenging topic in order to foster better communication and improved outcomes.
Miscarriage occurs in at least one out of every five pregnancies. Most of these miscarriages—estimated to be 60% to 80% depending on the woman’s age—are due to a genetic abnormality in the developing fetus. Yet a recent national survey demonstrated that both men and women in the USA believe that miscarriage is rare; occurring in fewer than 6% of pregnancies. Even worse, the same respondents felt that lifting heavy objects and stressful events were among the most common causes of pregnancy loss. Maybe this false sense of responsibility explains why feelings of guilt and shame are so frequently reported by patients following a miscarriage. So let’s set the record straight by reviewing what the science has taught us.
For a successful pregnancy to occur there are three critical factors. First, there must be a healthy, genetically competent embryo. Then the embryo must arrive into the woman’s uterus during the hormonally synchronized window of time to support implantation. Finally the blood flow to the implantation site and woman’s immunologic functions must foster the growth of the pregnancy along with providing continued hormonal support. So let’s consider what interventions we can take to assist women with recurrent pregnancy loss (REPL)—defined as at least two pregnancy losses—to improve their chance of delivering a healthy baby.
In general, REPL is fairly uncommon and occurs in less than 5% of women. However, it is becomes increasingly more frequent after the age of 35 due to the increased likelihood of producing genetically abnormal embryos associated with aging. Comprehensive chromosomal screening (CCS) involves performing a biopsy on developing embryos created through IVF. These biopsies can then be tested for missing or extra copies of all 24 (including X & Y) chromosomes in each embryo—the most common cause of miscarriage. Several studies have demonstrated that doing so can reduce the risk of miscarriage substantially. In fact, one recent study performed on women with REPL demonstrated that selecting and transferring only genetically competent embryos reduced the subsequent miscarriage rate to around 7%; making it three to five times less common than women that did not undergo this important test. So taking steps to insure that a pregnancy is started with an apparently healthy embryo is an effective strategy but some argue that it is too costly. Given that about half of the women with REPL are never given a diagnosis explaining why their pregnancy loss occurred; the insight gained from CCS might be considered invaluable. In fact, the lack of this diagnostic information likely fuels many of the other—often unnecessary—treatments offered to prevent subsequent miscarriage.
It has long been theorized that decreased blood flow and inflammation were major contributors to pregnancy failure and that low dose aspirin would help correct these problems. Unfortunately a randomized study involving over 1200 women with REPL demonstrated that using low-dose aspirin (started before conception) was no better than placebo in reducing the risk of subsequent miscarriage. Given that low-dose aspirin is inexpensive; many may continue to use it anyway on the outside chance that it may help some individuals with REPL even though it is clearly not a major preventative measure for most women. However, other more expensive and risky treatments are often suggested as well.
Since immunologic problems have long been theorized to contribute to recurrent pregnancy loss, treatment with intravenous immunoglobulin (IVIG) has been proposed for nearly two decades to modulate the immune response. In truth this expensive and potentially hazardous treatment has failed to show benefit in multiple studies. Nonetheless, it has recently been put to the test yet again. This time the study was a larger prospective, randomized trial where both the patients and their providers were blinded as to whether they were receiving the actual treatment or a placebo. The group studied included 82 patients that had each experienced four or more miscarriages in previous attempts at conception. Unfortunately, the live birth rate was no different between the treatment group and the placebo group. This is yet another study demonstrating that immunologic therapy is not likely to help most REPL patients.
Another strategy to reduce inflammation and improve blood flow as well as boosting health in general is to look at the patient’s diet and lifestyle. Obesity is associated with an increase in miscarriage risk as well as a higher risk of nearly every pregnancy related complication. Recently the Nurse’s Health Study II —a prospective monitoring of over 17,000 women that had conceived over 25,000 pregnancies provided some helpful insight. They found that pre-pregnancy weight gain and obesity were associated with a higher risk of miscarriage. So helping overweight or obese women with REPL to lose weight prior to pregnancy may be one of the best ways to help them have a baby as well as a healthier life.
Sharing the latest research on miscarriage is critical. Not only can it reassure and empower women but also help them avoid further heartache. It can also help prevent them from making emotionally based decisions to pursue treatments that may even cause further harm as well as financial hardship.
I’ve long been fascinated by how symptoms provide insight into underlying hormonal disturbances. A great example is the emerging research on sleep. Your body has a circadian rhythm or a daily cycle of when specific physiologic events are to occur. This process organizes everything from growth, digestion and repair to consolidation of memories and production of chemicals to regulate your mood. It also coordinates the growth and development of sperm and eggs. The hormone that regulates your circadian rhythm is called melatonin.
Melatonin is a hormone produced by an area of the brain called the pineal gland. Blood levels typically between midnight and about 4 am. Maybe more interesting is the fact that exposing your eyes to light can abruptly interrupt the production and release of this hormone that helps you sleep through the second half of the night. That’s also the time of night when various physiologic functions peak including testosterone production and ovulation.
This is just one of the many facts linking your sleep pattern with your fertility.
Most fertility clinics may not inquire about what role your circadian rhythm may be playing your chance of conception, a recent publication in Fertility & Sterility summarized over 200 studies on how melatonin may be influencing your reproductive function. Here are just a few key points:
- Melatonin is a potent anti-oxidant. Studies show that the process of ovulation produces free radicals which can damage an egg. This hormone is concentrated in the fluid that surrounds mature eggs and likely serves to protect them from harm.
- Melatonin influences the production of estradiol, progesterone and testosterone differently during varying stages of the menstrual cycle.
- Melatonin regulates the maturation capacity of an egg. One study demonstrated that women with a history of failed IVF cycles experienced improved fertilization rates after melatonin supplementation.
- Melatonin modulates the immune system. It is estimated that 30% of women with premature ovarian failure have an autoimmune component. Additionally, many women with recurrent early pregnancy loss also have an immunologic disorder. These situations offer potential intervention to improve outcome through normalization of the circadian rhythm.
- Various fertility problems may be influenced by a melatonin deficiency. For instance, women with PCOS tend to have lower than normal levels of melatonin in their follicular fluid and melatonin may influence endometriosis growth.
The best way to optimize melatonin production is to establish and maintain a normal sleep pattern. In some situations melatonin supplements or the use of long acting melatonin-like medications may be of benefit. If you haven’t considered the role that a good night sleep can play in your successful conception check out this sleep assessment tool.
Few disorders can be more difficult to diagnose or more frustrating to treat then recurrent early pregnancy loss (REPL). Traditional diagnostic criteria call for at least three pregnancy losses prior to evaluation and treatment of this vexing problem. With more women choosing to delay pregnancy until their thirties or even their forties, REPL can create an additional burden on their already limited opportunities to achieve a successful pregnancy. Ironically, as women age they are more likely to experience a miscarriage when/if they do become pregnant. A new technique called comparative genomic hybridization (CGH) offers couples some reassurance.
Studies show that most pregnancy losses (50-70%) are due to genetic abnormalities. In fact, the earlier that miscarriage occurs the more likely it is to be due to abnormal changes in the DNA. These are not typically abnormalities that are detected by testing the parents but rather spontaneous mutations that occur during early development. Moreover, they often go undetected by the most commonly used technique for genetic assessment, called G-banded karyotype analysis. That’s because karyotype analysis has limited resolution. It is only able to detect the addition or deletion of relatively large portions of the genetic code. By contrast however, CGH is able to detect genetic changes that are far smaller. In fact, this technique has been reported to identify genetic causes for unexplained mental retardation in about 10% of patients that had previously had a “normal” conventional genetic karyotype. Moreover, a study in the current issue of the journal Obstetrics & Gynecology found that CGH was able to identify genetic abnormalities in 13% of miscarriages that were missed using conventional genetic testing. More exciting still is the potential of CGH to detect certain abnormalities before birth.
Maybe the best use of this technique however is when testing is performed on embryos prior to becoming pregnant. Combining CGH with in vitro fertilization (IVF) allows us to perform a biopsy upon an embryo for genetic analysis prior to transfer into a woman’s uterus. Early data using IVF with CGH has been very reassuring. We’re finding that by identifying and transferring only the embryos that are determined to be genetically competent—meaning without identifiable deletions or additions to the genetic code—we may be able to double or even triple the chance of a healthy live birth. Since this technique is still relatively new, more studies are needed before it is widely accepted but it is already revolutionizing the diagnosis and treatment of couples seeking fertility treatment.
Although we still recommend prenatal screening once pregnancy is established, CGH can dramatically reduce the anxiety of couples during those critical weeks of the first trimester; especially those with a history of recurrent early pregnancy loss. Remembering when my wife and I conceived—both of us are in our forties—I know that we would have had fewer sleepless nights early in our pregnancy had we been able to have CGH as part of our fertility treatment. There is certainly an additional therapeutic benefit of that stress reduction as well!